Fungal infections of the skinFungal infections of the skinDermatophytosisDermatophytosis

CandidiasisCandidiasisPityriasis versicolorPityriasis versicolor

Deep fungal infectionsDeep fungal infections

Derotophyte infections (ringworm)Derotophyte infections (ringworm) CauseCauseThree generate of dermatophyte fungi cause tinea Three generate of dermatophyte fungi cause tinea infections (ringworm)infections (ringworm)::

11 . .Ttichophyton-skin, hair and nail infectionsTtichophyton-skin, hair and nail infections..22 . .Microsporum-skin and hairMicrosporum-skin and hair..

33 . .Epidermophyton-skin and nailEpidermophyton-skin and nail..

Dermatophytes invade the keratin only, and the Dermatophytes invade the keratin only, and the inflammation they cause is due to: inflammation they cause is due to:

-metabolic products of the fungus or -metabolic products of the fungus or -delayed hypersensitivity.-delayed hypersensitivity.

In general, zoophilic fungi (those transmitted to In general, zoophilic fungi (those transmitted to

humans by animals) cause a more severe inflammation humans by animals) cause a more severe inflammation than anthropophilic ones (spread from person to than anthropophilic ones (spread from person to

person).person).

Presentation and coursePresentation and course::Depends upon the site and strain of fungus involvedDepends upon the site and strain of fungus involved..

Tenia pedis (athlete's foot)Tenia pedis (athlete's foot)Most common type of fungal infection in humansMost common type of fungal infection in humans . .

The sharing of wash places (e.g. in showers) and of The sharing of wash places (e.g. in showers) and of swimming pools, predisposes to infectionswimming pools, predisposes to infection . .

Occlusive footwear encourages relapseOcclusive footwear encourages relapse..Most cases are caused by one of three organisms: Most cases are caused by one of three organisms: Trichophyton rubrumTrichophyton rubrum (the most common and the most (the most common and the most stubborn), stubborn), Trichphyton mentagrophytes var. Trichphyton mentagrophytes var. intrdigitale intrdigitale andand Epidermophyton floccosum Epidermophyton floccosum..

There are three common clinical patternsThere are three common clinical patterns::

11 . .Soggy interdigital scaling, particularlyin the fourth Soggy interdigital scaling, particularlyin the fourth and fifth interspace (all three organisms)and fifth interspace (all three organisms)..

22 . .Diffuse dry scaling of the sole (uaually Diffuse dry scaling of the sole (uaually T. rubrumT. rubrum))..33 . .Recurrent episodes of vesication (Recurrent episodes of vesication (usually T. usually T.

mentagrophytes var. interdigitale mentagrophytes var. interdigitale oror E. floccosum E. floccosum))..

Tenia of the nails (onychomycosis)Tenia of the nails (onychomycosis)::--Toenail infection usually associated with tinea pedis. Toenail infection usually associated with tinea pedis.

-The initial changes occur at the free edges of the -The initial changes occur at the free edges of the nails, which becomes yellow and crumblynails, which becomes yellow and crumbly . .

--Subangual hyperkeratosis, separation of the nail from Subangual hyperkeratosis, separation of the nail from its bed, and thickening may then followits bed, and thickening may then follow . .

--Usually only a few nails are infected but rarely all Usually only a few nails are infected but rarely all areare . .

--Fingernail lesions are similar, but less common, and Fingernail lesions are similar, but less common, and are seldom seen without a chronic are seldom seen without a chronic T. rubrumT. rubrum infection infection of the skin of the handsof the skin of the hands..

Tinea of the hands (tinea manum)Tinea of the hands (tinea manum)::This is usually asymmetrical and associated with tinea This is usually asymmetrical and associated with tinea

pedispedis . .T. rubrumT. rubrum may cause a barely perceptible erythema of may cause a barely perceptible erythema of one palm with a characteristic powdery scale in the one palm with a characteristic powdery scale in the creasescreases..

Tinea of the groin (tinea cruris)Tinea of the groin (tinea cruris)::--This is common and affects men more than womenThis is common and affects men more than women . .

--The eruption is sometimes unilateral or asymmetrical. The eruption is sometimes unilateral or asymmetrical. -The upper inner thigh is involved and lesions expand -The upper inner thigh is involved and lesions expand slowly to form sharply demarcated plaques with slowly to form sharply demarcated plaques with

peripheral scalingperipheral scaling . .--In contrast to candidiasis of the groin area, the In contrast to candidiasis of the groin area, the

scrotum is usually sparedscrotum is usually spared . .--A few vesicles or pustules may be seen within the A few vesicles or pustules may be seen within the

lesionslesions . .--The organisms are the same as those causing tinea The organisms are the same as those causing tinea

pedispedis..

Tinea of the trunk and limbs (tinea corporis)Tinea of the trunk and limbs (tinea corporis)::--Characterized by plaques with scaling and erythema Characterized by plaques with scaling and erythema

most pronounced at the peripherymost pronounced at the periphery . .--Few small vesicles and pustules may be seen within Few small vesicles and pustules may be seen within

themthem . .The lesions expand slowly, healing in the centre and The lesions expand slowly, healing in the centre and leaves a typical ring-like patternleaves a typical ring-like pattern..

Tinea of the scalp (tinea capitis)Tinea of the scalp (tinea capitis)This is usually a disease of childrenThis is usually a disease of children . .

The causative organism varies from country to The causative organism varies from country to countrycountry..

Fungi coming from animal sources (zoophilic fungi) Fungi coming from animal sources (zoophilic fungi) induce a more intense inflammation than those spread induce a more intense inflammation than those spread

from person to person (anthropophilic fungi)from person to person (anthropophilic fungi) . .

TypesTypes::11 . .In ringworm acquired from cattle, for example, the In ringworm acquired from cattle, for example, the

boggy swelling, with inflammation, postulation and boggy swelling, with inflammation, postulation and lymphadenopathy, is often so fierce that a bacterial lymphadenopathy, is often so fierce that a bacterial infection is suspected; such a lesion is called a kerion infection is suspected; such a lesion is called a kerion and the hair loss associated with it may be permanent. and the hair loss associated with it may be permanent. Tenia of the beard area is usually caused by zoophilic Tenia of the beard area is usually caused by zoophilic

species and shows the same featuresspecies and shows the same features . .

2. Anthropophilic organisms cause bald rather scaly 2. Anthropophilic organisms cause bald rather scaly areas with minimal inflammation and hairs broken off areas with minimal inflammation and hairs broken off 3-4 mm from the scalp. 3-4 mm from the scalp.

3. In favus, caused by 3. In favus, caused by T. schoenleiniT. schoenleini, crusts , crusts surrounding many scalp hairs, and sometimes leading surrounding many scalp hairs, and sometimes leading to scarring alopecia. to scarring alopecia.

ComplicationsComplications::11 . .Fierce ringworm of the scalp can lead to a Fierce ringworm of the scalp can lead to a

permanent scarring alopeciapermanent scarring alopecia..22 . .Fungal infection anywhere can induce vesication on Fungal infection anywhere can induce vesication on

the sides of fingers and palmsthe sides of fingers and palms..33 . .Epidemics of ringworm occur in schoolsEpidemics of ringworm occur in schools..

44 . .The usual appearance of a fungal infection can be The usual appearance of a fungal infection can be masked by mistreatment with topical steroids (tinea masked by mistreatment with topical steroids (tinea incognito)incognito)..

InvestigationsInvestigations::11 . .Microscopic examination of skin scrapping, nail Microscopic examination of skin scrapping, nail

clipping or a plugged hairclipping or a plugged hair . .The scrapping should be taken from the scaly margin The scrapping should be taken from the scaly margin of a lesion with a small curette or a scalpel glade, and of a lesion with a small curette or a scalpel glade, and clippings/scrapings from the most crumbly part of a clippings/scrapings from the most crumbly part of a

nailnail . .Broken hairs should be plucked with tweezers. Broken hairs should be plucked with tweezers. Specimens are cleared in potassium hydroxide. Specimens are cleared in potassium hydroxide. Branching hyphae can easily be seen using a Branching hyphae can easily be seen using a scanning(x10) or low-power (x25) objective lens. scanning(x10) or low-power (x25) objective lens. Hyphae may also be seen within a cleared hair shaft, Hyphae may also be seen within a cleared hair shaft, or spores may be noted around itor spores may be noted around it..

2. Cultures may be carried out in a mycology or 2. Cultures may be carried out in a mycology or bacteriology laboratory. bacteriology laboratory.

Transport medium is not necessary, and specimens Transport medium is not necessary, and specimens should be sent in folded black paper. should be sent in folded black paper.

The report may take as long as a month; microscopy is The report may take as long as a month; microscopy is much quicker.much quicker.

3. Wood's light (ultraviolet light) examination of the 3. Wood's light (ultraviolet light) examination of the scalp usually reveals a green fluorescence of the hairs scalp usually reveals a green fluorescence of the hairs

in in Microsporum audouiniMicrosporum audouini and and Microsporum canisMicrosporum canis infections. infections.

The technique is useful for screening children in The technique is useful for screening children in institutions where outbreaks of tinea capitis still institutions where outbreaks of tinea capitis still

sometimes occur, but some fungi (e.g. sometimes occur, but some fungi (e.g. Trichophyton Trichophyton tonsuranstonsurans) do not fluoresce.) do not fluoresce.

TreatmentTreatment::LocalLocal::This is all that is needed for minor skin infectionsThis is all that is needed for minor skin infections . .

The more recent imidazole preparations (e.g. The more recent imidazole preparations (e.g. miconazole and clotrimazole) and the allylamines miconazole and clotrimazole) and the allylamines

such as terbinafine should be applied twice dailysuch as terbinafine should be applied twice daily . .Magenta paint (Castellani's paint) although highly Magenta paint (Castellani's paint) although highly colored, is useful for exudative or macerated areas in colored, is useful for exudative or macerated areas in

body folds or toe websbody folds or toe webs . .Occasional dusting with an antifungal powder is Occasional dusting with an antifungal powder is useful to prevent relapsesuseful to prevent relapses..

Topical nail preparationsTopical nail preparations::Many patients prefer to avoid systemic treatmentMany patients prefer to avoid systemic treatment . .

For them a nail lacquer containing amorolfine is worth For them a nail lacquer containing amorolfine is worth a triala trial . .

It should be applied once or twice a week for 6 It should be applied once or twice a week for 6 monthsmonths..

It is effective against stubborn moulds such as It is effective against stubborn moulds such as HendersonulaHendersonula and and ScopulariopsisScopulariopsis . .

Both amorolfine and tioconazole nail solutions can be Both amorolfine and tioconazole nail solutions can be used as adjuncts to systemic therapyused as adjuncts to systemic therapy..

SystemicSystemic;;This is needed for tinea of the scalp or of the nails, and This is needed for tinea of the scalp or of the nails, and for widespread or chronic infections of the skin that for widespread or chronic infections of the skin that have not responded to local measureshave not responded to local measures..

Terbinafine: It acts by inhibiting fungal squaline epoxidase and does not

interact with the cytochromeP-450 system. It is fungicidal and so cures chronic dermatophyte infections

more quickly and more reliably than griseofulvin. For tinea capitis in children, for example, a 4 weeks course of terbinafine is effective as an 8 weeks course of griseofulvin.

Cure rates of 70-90% can be expected for infected finger nails after a 6weeks course of terbinafine, and for infected toe nails

after a 3 months course. It is not effective for pityriasis versicolor or Candida

infections.

Griseofulvin:Griseofulvin: was for many years the drug of choice for chronic was for many years the drug of choice for chronic

dermatophyte infections. dermatophyte infections. It has proved to be safe drug, but treatment may have to be It has proved to be safe drug, but treatment may have to be

stopped because of persistent headache, nausea, vomiting or stopped because of persistent headache, nausea, vomiting or skin eruption. skin eruption.

The drug should not be given in pregnancy or to patients with The drug should not be given in pregnancy or to patients with liver failure or porphyria. liver failure or porphyria.

It interacts with coumarin anticoagulants, the dose of which It interacts with coumarin anticoagulants, the dose of which may have to be increased. may have to be increased.

Its effectiveness falls if barbiturars are been taken at the same Its effectiveness falls if barbiturars are been taken at the same time.time.

Griseofulvin is bacteriostatic and treatment for infected nails Griseofulvin is bacteriostatic and treatment for infected nails has to be prolonged (an average of 12 months for finger nails, has to be prolonged (an average of 12 months for finger nails,

and at least 18 months for toe nails). and at least 18 months for toe nails). The disappointing results for toe nail infections seen in some The disappointing results for toe nail infections seen in some 30-40% of cases can be improved by the concomitant use of 30-40% of cases can be improved by the concomitant use of

topical nail preparations.topical nail preparations.

Itraconazole:Itraconazole: is now preferred to ketoconazole, which occasionally is now preferred to ketoconazole, which occasionally

damagesthe liver, and is reasonable alternative to terbinafine damagesthe liver, and is reasonable alternative to terbinafine and griseofulvin if these are contraindicated. and griseofulvin if these are contraindicated.

It is effective in tinea corporis, cruris and pedis; and also in It is effective in tinea corporis, cruris and pedis; and also in nail infections. nail infections.

Fungistatic rather than fungicidal, it interferes with cyochrome Fungistatic rather than fungicidal, it interferes with cyochrome P-450 system, so the review of any other medication being P-450 system, so the review of any other medication being

taken is needed before a prescription is issued. taken is needed before a prescription is issued. Its wide spectrum makes it useful also in pityriasis versicolor Its wide spectrum makes it useful also in pityriasis versicolor

and candidiasis.and candidiasis.

CandidiasisCandidiasis::CauseCause:: Candida albicansCandida albicans is a classic opportunistic pathogen is a classic opportunistic pathogen . .

Even in transient and local infections in the apparently Even in transient and local infections in the apparently fit, one or more predisposing factors such as obesity, fit, one or more predisposing factors such as obesity, moisture and maceration, diabetes, pregnancy, the use moisture and maceration, diabetes, pregnancy, the use of broad-specrtum antibiotics, or perhaps the use of of broad-specrtum antibiotics, or perhaps the use of the oral contraceptive pill, will often be found to be the oral contraceptive pill, will often be found to be

playing some partplaying some part . .Opportunism is often more obvious in the Opportunism is often more obvious in the overwhelming systemic infections of the overwhelming systemic infections of the immunocompromizedimmunocompromized..

PresentationPresentationOral candidiasisOral candidiasis;;

--One or more whitish adherent plaques appear on the One or more whitish adherent plaques appear on the mucous membranesmucous membranes . .

--If wiped off they leave an erythematous baseIf wiped off they leave an erythematous base . .--Under dentures, candidiasis will produce sore red Under dentures, candidiasis will produce sore red

areasareas . .--Angular stomatitis, usually in denture wears may be Angular stomatitis, usually in denture wears may be

candidiasiscandidiasis..

Candida intertrigoCandida intertrigo;; --A moist glazed area of erythema and maceration A moist glazed area of erythema and maceration

appears in a body fold; the edge shows soggy scaling, appears in a body fold; the edge shows soggy scaling, and outlying satellite papulopustulesand outlying satellite papulopustules . .

--These changes are most common under the breasts, These changes are most common under the breasts, and under the armpits and groin, but can also occur and under the armpits and groin, but can also occur between the fingers of those whose hands are often in between the fingers of those whose hands are often in

waterwater . .

Genital candidiasis:Genital candidiasis: -Present as a sore itchy vaginitis with white curdy -Present as a sore itchy vaginitis with white curdy

plaques adherent to the inflamed mucous membranes, plaques adherent to the inflamed mucous membranes, and a whitish discharge.and a whitish discharge.

-The eruption may extend to the groin folds. -The eruption may extend to the groin folds. -Conjugal spread is common; in males similar changes -Conjugal spread is common; in males similar changes

occur under the foreskin and in the groin. occur under the foreskin and in the groin. -Diabetes, pregnancy and antibiotic therapy are -Diabetes, pregnancy and antibiotic therapy are

common predisposing factors.common predisposing factors.

ParonychiaParonychia:: --Acute paronychia is usually bacterial, but in chronic Acute paronychia is usually bacterial, but in chronic

paronychia candida may be the sole pathogen, or be paronychia candida may be the sole pathogen, or be found with other opportunists such as proteus or found with other opportunists such as proteus or

pseudomonaspseudomonas . .

-Proximal and sometimes the lateral nail folds of one -Proximal and sometimes the lateral nail folds of one or more fingers becomes bolstered and red.or more fingers becomes bolstered and red.

-The cuticles are lost and small amounts of pus can be -The cuticles are lost and small amounts of pus can be expressed. expressed.

-The adjacent nail plate becomes ridged and -The adjacent nail plate becomes ridged and discolored. discolored.

-Predisposing factors include wet work, poor -Predisposing factors include wet work, poor peripheral circulation and vulval candidiasis.peripheral circulation and vulval candidiasis.

Chronic mucocutaneous candidiasisChronic mucocutaneous candidiasis:: --persistent candidiasis, affecting most or all of the persistent candidiasis, affecting most or all of the

areas described above, can start in infancyareas described above, can start in infancy . .--Sometimes the nail and the nail folds are involvedSometimes the nail and the nail folds are involved . .

--Candida granulomas may appear on the scalpCandida granulomas may appear on the scalp . .--Several different forms have been described Several different forms have been described

including those with autosomal recessive and including those with autosomal recessive and dominant inherited patternsdominant inherited patterns . .

-In the candida endocrinopathy syndrome, chronic -In the candida endocrinopathy syndrome, chronic candidiasis occurs with one or more endocrine defect, candidiasis occurs with one or more endocrine defect,

the most common of which are hypoparathyroidism, the most common of which are hypoparathyroidism, and addison's disease. and addison's disease.

-A few late onset cases have underlying thymic -A few late onset cases have underlying thymic tumours.tumours.

Systemic candidiasis:Systemic candidiasis: -This is seen against a background of severe illness, -This is seen against a background of severe illness,

leukemia and immunosupression. leukemia and immunosupression. -The skin lesions are firm red nodules, which can be -The skin lesions are firm red nodules, which can be

shown by biopsy to contain yeasts and pseudohyphae.shown by biopsy to contain yeasts and pseudohyphae.

Investigations:Investigations:-Swabs from suspected areas should be sent for -Swabs from suspected areas should be sent for

cultures. cultures. -The urine should always be tested for sugar. -The urine should always be tested for sugar.

-In chronic mucocutaneous candidiasis, a detailed -In chronic mucocutaneous candidiasis, a detailed immunological work-up will be needed, focusing on immunological work-up will be needed, focusing on

cell mediated immunity.cell mediated immunity.

Treatment: Treatment: -Predisposing factors should be sought and eliminated; -Predisposing factors should be sought and eliminated;

e.g. dental hygiene may be important. e.g. dental hygiene may be important. -Infected skin folds should be separated and kept dry. -Infected skin folds should be separated and kept dry.

-Those with chronic paronychia should keep their -Those with chronic paronychia should keep their hands worm and dry. hands worm and dry.

--Amphotericin, nystatin, and the imidazole group of Amphotericin, nystatin, and the imidazole group of compounds are all effective topically, for the mouth, compounds are all effective topically, for the mouth, these are available as oral suspensions, lozenges and these are available as oral suspensions, lozenges and

oral gelsoral gels . .--False teeth should be removed at night, washed and False teeth should be removed at night, washed and

steeped in a nystatin solutionsteeped in a nystatin solution . .

--For other areas of candidiasis, creams, ointments and For other areas of candidiasis, creams, ointments and pessaries are availablepessaries are available..

--Magenta paint is also useful but messy for the skin Magenta paint is also useful but messy for the skin flexuresflexures . .

--In chronic paronychia, the nail folds can be packed In chronic paronychia, the nail folds can be packed with an imidazole cream or drenched in an imidazole with an imidazole cream or drenched in an imidazole

solution several times a daysolution several times a day . .

-Genital candidiasis responds well to a single day's -Genital candidiasis responds well to a single day's treatment with either itraconazole and fluconazole. treatment with either itraconazole and fluconazole.

Both are also available for recurrent oral candidiasis Both are also available for recurrent oral candidiasis of the immunocompromized, and for the various types of the immunocompromized, and for the various types

of chronic mucocutaneous candidiasis.of chronic mucocutaneous candidiasis.

Pityriasis versicolorPityriasis versicolor::CauseCause;;

--Commensal yeasts (Commensal yeasts (pityrosporum orbiculrepityrosporum orbiculre), ), overgrowth of these, particularly in hot humid overgrowth of these, particularly in hot humid conditions, is responsible of the clinical lesionsconditions, is responsible of the clinical lesions..

--Carboxylic acids released by the organisms inhibit Carboxylic acids released by the organisms inhibit the increase in pigment production by melanocytes the increase in pigment production by melanocytes

that occurs normally after exposure to sunlightthat occurs normally after exposure to sunlight . .--The term versicolor refers to the way in which the The term versicolor refers to the way in which the

superficial scaly patches, fawn or pink on non-tanned superficial scaly patches, fawn or pink on non-tanned skin, become paler than the surrounding skin after skin, become paler than the surrounding skin after

exposure to sunlightexposure to sunlight . .--The condition should be regarded as non-infectiousThe condition should be regarded as non-infectious..

Presentation and coursePresentation and course:: --The fawn or depigmented areas, with their slightly The fawn or depigmented areas, with their slightly

branny scaling and fine wrinkling, look uglybranny scaling and fine wrinkling, look ugly . .--Otherwise they are symptom-free or only slightly Otherwise they are symptom-free or only slightly

itchyitchy . .--Lesions are most common on the upper trunk but can Lesions are most common on the upper trunk but can

become widespreadbecome widespread . .--Untreated lesions persist, and depigmented areas, Untreated lesions persist, and depigmented areas,

even after adequate treatment, are slaw to regain their even after adequate treatment, are slaw to regain their former colorformer color . .

--Recurrences are commonRecurrences are common..

Differential diagnosis:Differential diagnosis:-In -In vitiligovitiligo, the border is clearly defined, scaling is , the border is clearly defined, scaling is

absent, lesions are larger, the limbs and face are often absent, lesions are larger, the limbs and face are often affected , and depigmentation is more complete; affected , and depigmentation is more complete;

however, it may sometimes be hard to distinguish however, it may sometimes be hard to distinguish vitiligo from the pale non-scaly areas of treated vitiligo from the pale non-scaly areas of treated

versicolor. versicolor. -Seborrhoeic eczema-Seborrhoeic eczema of the trunk tends to be more of the trunk tends to be more

erythematous, and is often confined to the presternal erythematous, and is often confined to the presternal or interscapular areas. or interscapular areas.

-Pityriasis alba-Pityriasis alba often affects the cheeks. often affects the cheeks. -Pityriasis rosea, tinea corporis, secondary syphilis -Pityriasis rosea, tinea corporis, secondary syphilis

and erythrasmaand erythrasma seldom cause real confusion. seldom cause real confusion.

Investigations:Investigations: -Scrapings, prepared and examined as for the -Scrapings, prepared and examined as for the

dermatophyte infection, show a mixture of short dermatophyte infection, show a mixture of short branched hyphae and spores ( a spaghetti and meat-branched hyphae and spores ( a spaghetti and meat-

balls' appearance). balls' appearance). -Culture is not helpful.-Culture is not helpful.

TreatmentTreatment:: --a topical preparation of one of the imidazole group of a topical preparation of one of the imidazole group of

anti-fungal drugs can be applied at night to all affected anti-fungal drugs can be applied at night to all affected areas for 2-4 weeksareas for 2-4 weeks . .

--Equally effective, but messier and more irritant, is a Equally effective, but messier and more irritant, is a 2.5% selenium sulphide mixture in a detergent base 2.5% selenium sulphide mixture in a detergent base (selsun shampoo). This should be lathered on to the (selsun shampoo). This should be lathered on to the patches after an evening bath, and allowed to dry. patches after an evening bath, and allowed to dry. Next morning it should be washed off. Three Next morning it should be washed off. Three

applications at weekly intervals are adequateapplications at weekly intervals are adequate . .

-A shampoo containing ketoconazole is now available -A shampoo containing ketoconazole is now available and is less messy, but just as effective as the selenium and is less messy, but just as effective as the selenium

ones. ones. -For wide spread or stubborn infections systemic -For wide spread or stubborn infections systemic

itraconazole (200mg daily for 7 days) has been shown itraconazole (200mg daily for 7 days) has been shown to be curative, but interactions with other drugs must to be curative, but interactions with other drugs must

be avoided. be avoided. -Recurrence is common after any treatment.-Recurrence is common after any treatment.

Deep fungal infectionsDeep fungal infections::HistoplasmosisHistoplasmosis::

--Histoplasma capsulatumHistoplasma capsulatum is found in soil and in the is found in soil and in the droppings' of some animals (bat)droppings' of some animals (bat) . .

--Airborn spores are inhaled and cause lung lesions, Airborn spores are inhaled and cause lung lesions, which are in many ways like those of tuberculosiswhich are in many ways like those of tuberculosis . .

--Later, granulomatous skin lesions may appear, Later, granulomatous skin lesions may appear, particularly in the immunocompromisedparticularly in the immunocompromised . .

--Amphotericin B or itraconazole given systemically, is Amphotericin B or itraconazole given systemically, is often helpfuloften helpful..

CoccidioidomycosisCoccidioidomycosis:: --The causative organism, The causative organism, Coccidioides immitisCoccidioides immitis, is , is

present in the soil in arid areas in the USApresent in the soil in arid areas in the USA . .--Its spores are inhaled, and the pulmonary infection Its spores are inhaled, and the pulmonary infection

may be accompanied by a fevermay be accompanied by a fever . .--At this stage erythema nodosum may be seenAt this stage erythema nodosum may be seen . .

--In a few patients the infection becomes disseminated, In a few patients the infection becomes disseminated, with ulcers or deep abscesses in the skinwith ulcers or deep abscesses in the skin . .

--Treatment is with amphotericin B or itraconazoleTreatment is with amphotericin B or itraconazole..

BlastomycosisBlastomycosis:: --Infections with Infections with Blastomyces dermatitidisBlastomyces dermatitidis are virtually are virtually

confined to rural areas of the USAconfined to rural areas of the USA . .--Rarely, the organism is enoculated into the skin; more Rarely, the organism is enoculated into the skin; more

often it is inhaled and then spreads systemically from often it is inhaled and then spreads systemically from the pulmonary focus to other organs including the the pulmonary focus to other organs including the

skinskin . .--There the lesions are wart-like, hyperkeratotic There the lesions are wart-like, hyperkeratotic

nodules, which spread peripherally with a verrucose nodules, which spread peripherally with a verrucose edge, while tending to clear and scar centrallyedge, while tending to clear and scar centrally . .

--Treatment is with amphotericin B or itraconazoleTreatment is with amphotericin B or itraconazole..

SporotrichosisSporotrichosis:: --The causative fungus The causative fungus Sporotrichum schenckiSporotrichum schencki, lives , lives

supprophytically in soil or on wood in warm humid supprophytically in soil or on wood in warm humid countriescountries . .

--Infection is through a wound, where later a lesion like Infection is through a wound, where later a lesion like an indolent boil arisesan indolent boil arises . .

--Later still, nodules appear in succession along the Later still, nodules appear in succession along the draining lymphaticsdraining lymphatics . .

--KI or itraconazole are both effectiveKI or itraconazole are both effective..

ActinomycosisActinomycosis:: --The causative organism, The causative organism, Actinomyces IsraeliActinomyces Israeli, is , is

bacrerial but traditionally considered with a fungibacrerial but traditionally considered with a fungi . .--It has long branching hyphae and is part of the It has long branching hyphae and is part of the

normal flora of the mouth and bowelnormal flora of the mouth and bowel . .--In actinomycosis, a lumpy induration and scarring In actinomycosis, a lumpy induration and scarring

coexist with multiple sinuses discharging puss coexist with multiple sinuses discharging puss containing sulphur granules, made up of tangled containing sulphur granules, made up of tangled

filamentsfilaments . .--Favourite sites are the jaw, and the chest and Favourite sites are the jaw, and the chest and

abdominal wallsabdominal walls . .--Long-term penicillin is the treatment of choiceLong-term penicillin is the treatment of choice..

Mycetoma (Madura foot)Mycetoma (Madura foot):: --Various species of fungus or actinomycetes may be Various species of fungus or actinomycetes may be

involvedinvolved . .--They gain access to the subcutaneous tissues, usually They gain access to the subcutaneous tissues, usually

of the feet or legs, via a penetrating woundof the feet or legs, via a penetrating wound . .--The area becomes lumpy and distorted, later The area becomes lumpy and distorted, later

enlarging and developing multiple sinusesenlarging and developing multiple sinuses . .--Puss exuding from these shows tiny diagnostic Puss exuding from these shows tiny diagnostic

granulesgranules . .--Surgery may be a valuable alternative to the often Surgery may be a valuable alternative to the often

poor results of medical treatment, which is with poor results of medical treatment, which is with systemic antibiotics or anti-fungal drugs, depending systemic antibiotics or anti-fungal drugs, depending

on the organism isolatedon the organism isolated . .